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Mn DOT Employee/Public Incident Statement
Employee Name:Date:
District:
Assigned Work Area:
Immediate Supervisor:
Date Reported:
Time:
Witnesses:Reported By:
Reported To (Dispatch, Law Enforcement):
Date
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Typically, the information reported on a 0 check includes identification details of the filer, the reporting period, and confirmation that there were no transactions or changes to report for that period.
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